Basic Care and Comfort

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse’s greatest concern at this time is:
-Addressing the pain
-Reversing feelings of hopelessness
-Promoting mobility in the residual limb
-Acknowledging the grieving for the lost limb

Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying?
-Offer a pacifier.
-Provide a baby rattle
-Hang a mobile over the crib.
-Wrap a soft blanket around the baby

During infancy, sucking provides comfort through oral gratification. A rattle may provide visual and tactile stimulation, not comfort. A mobile provides visual stimulation, not comfort. A blanket may stimulate tactile senses through texture, but it does not provide comfort to a hungry infant.

A nurse concludes that a client understands the teaching about limiting the discomfort associated with a hiatal hernia when the client states, “After meals I will:
-Drink 8 oz of water.”
-Take a 10-minute walk.”
-Rest in a sitting position for one hour
-Lie down in bed for at least 20 minutes

Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus. Water should not be taken with or immediately after meals because it overdistends the stomach. Exercise immediately after eating may prolong the digestive process. Lying down in bed for at least 20 minutes is not an appropriate action because it promotes the reflux of gastric contents into the esophagus.

Dehydration leads to reduced blood volume, which in turn reduces kidney perfusion, resulting in a decreased urine output. The anterior fontanel is depressed in the dehydrated infant; it is level in an adequately hydrated infant. A dehydrated infant’s skin is cold, and respiration is rapid.

A client with chronic hepatic failure is to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider’s prescription?
-High-fat
-Low-calorie
-Low-protein
– High-sodium

With liver failure, the protein intake is limited to 20 g daily to decrease the possibility of hepatic encephalopathy. A high-fat diet is avoided because of the related cardiovascular risks and the related demand for bile. Regeneration of tissue requires a high-calorie, high-carbohydrate diet. Sodium usually is restricted to decrease the accumulation of fluid and help limit ascites and edema.

An obese client with a hiatal hernia asks the nurse how to prevent esophageal reflux. What is the nurse’s best response?
-“Lie down after eating.”
-“Eat less food at each meal.”
-“Increase your intake of fat.”
-“Drink more fluid with each meal.”

Eating less food not only relieves intraabdominal pressure, but it promotes weight loss, which helps to decrease the tendency of gastric contents to reflux into the esophagus. The response “Lie down after eating” increases pressure against the diaphragmatic hernia, thereby increasing symptoms. Fats decrease emptying of the stomach, extending the period during which reflux can occur; fats should be decreased. The response “Drink more fluid with each meal” will increase intraabdominal pressure; fluid should be discouraged with meals.

An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. What is the best response by the nurse?
-“It limits the chance of vomiting.”
-“It allows the feeding to be administered rapidly.”
-“The energy that would have been expended on suckling is conserved.”
-“The quantity of nutritional liquid can be regulated better than it can with a bottle.”

Gavage feeding is preferred for weak infants, those with respiratory distress or ineffective sucking-swallowing coordination, and those who are easily fatigued. It conserves energy and reduces the workload of the heart. Vomiting is not a reason to institute gavage feedings; however, vomiting may be lessened because the amount and rapidity of the feeding can be controlled. Feeding the infant quickly is not desirable; vomiting followed by aspiration may occur. The amount given can be regulated with oral formula feeding as well.

A nurse is caring for a client during the manic phase of bipolar disorder. What should the nurse do to best help meet the nutritional needs of this client?
-Provide a tray in the client’s room.
-Assure the client that the food is deserved.
-Point out that the energy the client is burning up must be replaced.
-Order foods that the client can hold in the hand to eat while moving around

The hyperactive client should be given handheld foods that do not require sitting down to eat. The client most likely will ignore the tray. Unworthy feelings may be part of a depressive, not manic, episode. It is unlikely that the client will understand or care about the need to replenish lost energy.

A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence?
-Restricting fluid intake
-Offering the urinal regularly
-Applying incontinence pants
-Inserting an indwelling urinary catheter

Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection, promotes an atonic bladder, and prolongs incontinence. Also, it requires a health care provider’s prescription.

A nurse is caring for a client with acute kidney failure who is receiving a protein restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client’s questions?
– A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses.
-Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis.
-This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.
-Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

The amount of protein permitted in the diet (usually less than 50 g) depends on the extent of kidney function; excess protein causes an increase in urea concentration, which should be avoided Adequate calories are provided to prevent tissue catabolism that also results in an increase in metabolic waste products. In kidney failure the kidneys are unable to eliminate the waste products of a high-protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.